Reducing “Road Rage” in Nursing Home Residents

So, maybe in seeing this title, what came to mind for you was the idea of nursing home residents crowding hallways and griping at each other about who gets to pass first (I work in a nursing home for veterans – a nearly all-male facility, so this actually happens fairly frequently). So, no, wheelchair “traffic jams” isn’t what I had in mind…. Although that might be a good topic for another post. I’ll make the connection in a few paragraphs here, below.

What I had in mind was the subject of the “call button,” something all residents of nursing homes (and pretty much anyone who’s ever spent any time as a patient in a hospital) knows about:

Hospital call bell

For residents in nursing homes, overwhelmingly older adults, many of whom who are completely dependent on nursing staff for their mobility, food, water, and other ADLs, the call button represents pretty much a lifeline. If you have a need to use the bathroom (and you’re able to use the toilet), but you need help from a staff member to get up from your bed safely, you hit the call button.

And you wait. And sometimes, you wait some more.

Although I haven’t run the numbers myself at the Community Living Center I work at (e.g., the nursing home care unit of the Palo Alto VA system), I would guess a significant proportion of both falls and behavioral issues such as yelling, verbal abusiveness, and agitation, are related to the interval between the time a call bell is answered (e.g., via intercom – a nurse usually answers and a disembodied voice speaks in the patients room, “how can I help you”), and the time it takes for a nurse to arrive in a residents’ room. There seems to be some consensus that extended wait times for call bells to be answered can be a contributor to fall risk (see here).

This makes intuitive sense, of course – the longer you wait (and the more urgent your need is), the more agitated and anxious you will be if you’re a resident / nursing home patient in need, correct? This seems to suggest a straightforward, technological or human-resources approach to fix to the problem – just increase staffing, or more intelligently balance staffing in order to minimize as much as possible the amount of time it takes for nursing staff to reach a patient who has depressed their call button.

Of course, there’s another take on this. While the above approach of increasing staffing obviously helps with the task of offering quality nursing care – it ignores the psychological dimension, and a possible psychological solution to the problem of the call button wait time intervals (as an aside, for a wonderful discussion of the value of paying homage to the psychological dimension in addressing human problems, I highly recommend viewing this “TED Talk” with UK advertising executive Rory Sutherland…. Goes to show you that sometimes the best psychologists are often people in the marketing field).

So what’s this possible solution? This brings us back to “road rage.” Imagine yourself at a red light (not hard to imagine for many of you – you may have had to wade through a dozen of them prior to getting to the office this morning). How many of you feel agitated, impatient, somewhat anxious when you’re at a red light and you’re on your way to an appointment, or to work? Most of us. Of course, studies have reportedly shown that longer, unjustified wait times for red lights increases driver frustration and can lead to increases in accidents – so again, the simple, technological approach, is to use advanced signaling technology, more intelligent use of sensors, etc., to minimize unjustified wait times at intersections, and to therefore decrease driver frustration and accidents. Of course, there’s a problem – drivers will still have to wait.

This stoplight, a really brilliant invention in my view, has as a feature a visual progress bar which gives immediate feedback to drivers at intersections how long they have to wait prior to the signal changing to green. Apparently there is data from Korea and also other data from the manufacturer that strongly suggests that this innovation significantly decreases red light running and accidents at intersections. Put simply – without even changing the wait time interval at traffic intersections, people are more able to be patient and wait, because they know how long they have to wait. And as you know, a minute at an intersection when you’re late for an appointment can sometimes feel like a hour!

So what if such an innovation could be applied to wait times for residents in nursing homes? As far as I can tell – although there is active work on improving call-bell technology in inpatient units (e.g., experimenting with wireless technology and IP-based call systems), as yet I have not seen this idea applied to the nursing home environment. But maybe it should! It would take some work – as my wife pointed out the other night, the Eko Stoplight idea doesn’t precisely map onto the nursing home situation – while the interval between when a stoplight goes from red to green is known precisely (thereby allowing the Eko to precisely calibrate the progress bar), the amount of time it takes for a nurse to reach your room after a call bell is activated tends to vary based on staffing, workload, and other factors. Still, one way of getting around that is allowing individual nurses to calibrate their assigned residents’ progress bars (their ‘Eko timers’) on-the-fly. As long as a nurse arrived before the progress bar elapsed in the patients’ room, I think this psychological, calming effect would still potentially hold. There could be other ways of implementing this idea.

4 thoughts on “Reducing “Road Rage” in Nursing Home Residents”

It’s certainly a valid issue. I know that when my mother was in a nursing home, this wait time issue certainly bothered her. And in the studies of computer systems that my colleagues at RAND Corporation and I did a good many years ago, the single best predictor (by a large margin) of satisfaction with the system overall was “cursor hang time” – the time after you moved the cursor to some place and clicked and before the action executed. I expect that most of us would agree that this still characterizes our interactions even with our PCs.

It ought not to be too difficult to implement a call system based on wi-fi and connected to a server that would also have staff tracked on what they are doing, running a relatively simple algorithm that would estimate the time before a particular staff member was ready based on average times to complete a particular kind of activity. The system then could message back to the patient an estimated wait time – perhaps slightly over-estimated in order to increase the chances of the staff member arriving before the time ran out.

This would require that the staff agree to carry some sort of wi-fi-enabled device and key into it a code for their current activities. Obviously, this would be a fairly major socio-technical intervention, and would need to be handled carefully so that the staff didn’t see it as a way for management to monitor their time more closely but more as a way of reducing the frustration and anger of the patients with which they would have to cope.

This is an interesting problem for which there is a fairly clear technical solution. It wouldn’t even be very expensive – a few hundred dollars for hardware and get a smart high school or college kid to develop your algorithm on an internship. The temptation would then be to implement this as a technical change. But unless it is appreciated as a socio-technical problem and appropriate socio-tech interventions implemented, it would be almost guaranteed to fail.

I do tend to ride my socio-technical horse in all rodeos. Thanks for the chance to ride in this one!

Nice post, Geoff. This is the same principle used by call centers when they’re instructed to tell callers where they are when looking on their computer, trying to find the answer to the caller’s question, or saying anything to fill the silence before they can fix the caller’s problem. Apparently, callers don’t like dead time. It’s really all about communication, and respecting the wishes/needs of the person making the request, and explaining why there’s a delay. Usually, it’s the process that matters more than the content. Thanks for the opportunity to comment.